This map shows the percentage of people under 65 without health insurance in every rural and exurban county in the country. Green counties have uninsured rates below the national average. Brown and red counties have rates above the national average.

Insured for Health Care: Rural and Urban

More people in rural America have health insurance than in the cities. But that's not the whole story.

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A slightly higher percentage of rural Americans has health insurance than do urbanites, according to a new study conducted by the U.S. Census Bureau. But there are large disparities in health care coverage state-to-state.

In rural counties as of 2006, 82.6% of people under the age of 65 (when Medicare coverage begins) had some kind of health insurance coverage. In urban counties, 82% of those under 65 years of age had health care coverage.

Exurbia had the highest rate of insured residents. In exurban counties, 83.4% of those under 65 had health insurance, according to the Daily Yonder’s calculations. (A map of rural, urban and exurban counties can be found here.)

The map above shows how all the nation’s rural and exurban counties compare to the national average. In the United States, 17.8 percent of those under 65 don’t have any health insurance. The green counties on the map are doing better than the national average. They have uninsured rates below 17.3 percent.

Brown and red counties have higher percentages of people without health insurance than 18.3 percent. Urban counties are in white. Click here or on the map to enlarge the image. Nationally, a higher percentage of people living in cities are without health insurance than in rural counties.

Nationally, rural residents are more likely to have health care coverage than those who live in the cities. That fact, however, is misleading. Several largely urban states — Texas, Florida, Arizona and California — have very high rates of uninsured. (See the chart below.) The large number of insured people in those states’ cities tipped the national figures.

Comparing rural and urban rates of uninsured state by state tells a very different story.

In eight out of ten states (37 out of 48 states with rural populations), rural residents were LESS likely to have health insurance than their urban neighbors in 2006.

In all but nine states, the percentage of uninsured was HIGHER in rural areas than the state average.

The widest gap between rural and urban counties was in Delaware, where 11.8% of urban residents and 18.8% of rural residents lacked health insurance in 2006 — a gap of 7 percentage points. In Idaho, the gap between rural and urban rates of those without health insurance was 5.7 percentage points. In Massachusetts it was 5.6 percentage points. In Colorado, it was 5.4 percentage points; 5 percentage points in South Dakota; and 4.6 percentage points in Nebraska.

Rural rates of uninsured were lower than in the cities in only 11 states. The largest gap was in Arizona, where 18.5 percent of rural residents lacked health insurance while in the cities 22.2 percent of those under 65 didn’t have insurance — a gap of 3.7 percentage points.

(The eleven states where rural rates of uninsured were lower than urban rates in 2006 were Arizona, Illinois, California, Nevada, Connecticut, Texas, South Carolina, Iowa, West Virginia, Indiana and Louisiana.)

Below is a chart showing the rates of uninsured in rural, exurban and urban counties in every state. (For a definition of rural, exurban and urban counties, go here.)

There has been little work done to compare rural and urban rates of health insurance coverage. The Kaiser Family Foundation issued a report in 2003 on health insurance in rural America. The Kaiser study emphasized that rural areas adjacent to metro areas were entirely different from rural counties that were more remote.

Kaiser found that 24 percent of those living in remote rural areas were uninsured. In urban areas and those counties adjacent to metro areas, 18 percent lacked health insurance.

“Residents of rural, non-adjacent (to metro areas) counties have the lowest rate of private health insurance, largely because they are less likely to be offered health benefits through their jobs,” Kaiser reported. Workers in these more rural counties were more likely to be earning low wages (then, under $7 an hour), and in remote areas low-wage workers made up 60 percent of all uninsured workers, compared to 40 percent of the uninsured workers in the cities.

The Census Bureau study reported here is based on a combination of sources — surveys, tax returns and Medicaid records. Counting the number of uninsured at the county level is imprecise, but this is the best the Census Bureau has to offer.

To download an Excel file showing all U.S. counties and the numbers of those without health insurance, click here.